ON THE MEDICAL-SURGICAL FIRE LINES

In 1984, I had data about surgical outcomes by surgeon for carotid endarterectomy (CEA) in two Tucson hospitals. There was a 14% major complication rate and a 23% overall complication rate, clearly worse than the results that we knew about medical management of the condition. I referred my potential surgical cases to only one surgeon, whose outcomes were comparable to medical management; many patients, when told that the local outcomes, refused surgery altogether. I took a great deal of heat from my colleagues for my stance. So be it. My patients mattered more.

I saw far too many complications post-operatively when I had not been involved pre-operatively. In my view, many of these procedures, especially every asymptomatic CEA, were not indicated. Some agreed with me. Not many. That of course, isn’t the only turf battle in medicine. There are many. Patient care quality is often mentioned; I wonder today how much outcomes data is collected, how well it is collected, and whether decisions are made based upon it. I would hope so. However, as a physician with advanced training in statistics and quality, I never was called upon in this state to offer my opinion.

Before last summer’s fires, I wondered how many in Sierra Vista, a conservative city, had decried big government, only to realize that they needed the resources of the National Interagency Fire Center to save property, lives and indeed the city.

The National Interagency Fire Center was created by combining of three governmental agencies to cut duplication (waste)–the US Forest Service, the Bureau of Land Management and the National Weather Service. Eight different federal agencies are now part of the NIFC, which has no single head. That isn’t to say that firefighting is done without an incident commander. There is one. But the organization itself has no CEO.

Aside from cutting waste, the NIFC did one other remarkable action: they coordinated nationwide firefighting. Instead of each state having its own cadre of firefighters, on duty only for that state, the condition of the COUNTRY was looked at, so that wild land firefighters in Oregon might be called upon to fight a fire in Utah, because the latter was more severe than any fire burning in Oregon at that time.

This approach required that firefighting managers in a state give up local turf for the good of the country. Incredibly, they did. And we are better for it. Congress would do well to follow that example.

That isn’t to say that the NIFC always gets it right. The Fire of 1910 colored our wild land firefighting thinking for decades as sure as a missed diagnosis often colors a physician’s thinking for the rest of their practice. Sometimes fire fighters, in spite of their training, do the wrong thing, as in Colorado’s Storm King fire in 1994 or the Thirty Mile Fire in Washington in 2001. But there were no calls to dissolve the NIFC, to hand it over to the states, or worse, to local people, to handle matters themselves. The fire deaths were investigated thoroughly, and the mistakes publicized, in hopes that they would not be repeated, although the Storm King fire deaths unfortunately paralleled those of the Mann Gulch fire in Montana in August 1949.

Without the NIFC, Sierra Vista, Alpine, Greer, Springerville, Pinetop/Show Low would not exist as we know them. To me, that smacks as government doing something right, something that government should do, that individuals on their own, no matter how motivated, simply cannot do. It is quite easy to set government up to fail. I see that today. It is far more difficult, but far more rewarding, to set government up to do good, to step in where individuals simply cannot deal with circumstances that are overwhelming, like severe poverty, catastrophic medical emergencies, education, or natural disasters. Katrina was bad; the gutting of FEMA prior to that put the US on world-wide display as an incompetent country. How many died because of that?

How much government we should have is a matter of opinion. Frankly, I am willing to pay taxes, and a lot of them, to ensure we have a country that properly helps lead the world.

Like the NIFC, government won’t always get it right. But I am incapable of defending myself from wild land fires or knowing if my food, water or an aircraft are safe. I depend upon somebody in government to have firefighters in place, mandatory food safety inspections, oversight of the financial system, and an aircraft control system, so that the results of unpreventable disasters are minimized and we prevent what can be prevented.

I want to know which physicians are best for me, should I need a bronchoscopy, colonoscopy, back surgery, or have a carotid event. I hope my colleagues have sorted this problem out by now, but I don’t know, despite bringing a wealth of skills to the table. Perhaps we need a National Interagency Medical Quality System, assuming we can find enough people to give up some turf and do what is right for the patient. Like the NIFC, they wouldn’t get it right all the time, but it would be a step in the right direction. Heck, I might come out of retirement to serve, should anybody ask.